Developing documentation guidelines-for pen-and-paper or computerized records-is an essential prerequisite to evaluating the clinical efficiency and cost-effectiveness of any health care facility. Proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation. Once established, the documentation system should become the framework of clinical practice for all members of the wound care team.
This column focuses on the strategies necessary to create a solid documentation process for facilities that provide wound care. Wound care documentation can combine a variety of information reflecting the skin and wound's status across the healing continuum. Providing an accurate description of the skin and the wound's characteristics is critical during each patient visit. These findings assist the clinician in mapping the care during the wound management process. Wound classification establishes a common language for wound assessment and wound healing. It helps to foster sound clinical judgments, provides a universal scheme for documentation, and allows better evaluation of treatments Table 1.
Accurate measurements of wound size complement and complete the classification of a wound. Other essential documentation elements include a description of the skin around the wound, the wound's surface (intact, exuberant granulation tissue, or necrotic tissue), and the drainage or exudate found in the wound. Three main types of classification systems are used; two are based on the degree of tissue layer destruction, and one is based on the color of the wound bed.
Technology has significantly advanced, but documentation remains the weakest part of the chart for skin and wound care. Whether work is collected on paper or by a computer program, developing a consistent template or database for documentation is part of the solution to complete this process. Knowledge of the disease process and understanding the database are imperative to make a whole medical record and to use the tools correctly.